Provider Portal

Create a New Account - Enter User Information

Enter the information below for your new account.

Organizational Information

Account Information

Username: *

Password: *

Confirm Password: *

Enter a secret question: *

Enter the secret answer: *

Contact Information

First Name: *

Last Name: *

Address:

City:

State:

Zip:

Email Address: *

Confirm Email:

Phone Number:

Providers in receipt of Faxed determination letters: Official communication of service authorization will be sent to the fax number entered below.

Fax Number: *

* denotes required field